CHAPTER 21
Gender Dysphoria
Gender and sexuality are core aspects of the human experience. Consequently, medical students and students of psychiatry should be informed and conversant about such issues as normative sexual development, gender roles, gender identity, and sexual orientation. Given the complexity of this area, it is important to start with several definitions. Gender identity is an individual's perception and self-awareness of being male or female. Gender role is the behavior (usually culturally defined) in which an individual engages that identifies him or her to others as being male or female. Sexual orientation "refers to erotic attraction to males, females, or both" (American Psychiatric Association 2000a, p. 535). Table 21-1 provides definitions of core concepts relevant to this chapter's topic.
This chapter focuses on gender dysphoria in children, adolescents, and adults. It is important when working with individuals and families struggling with issues related to gender and sexuality to have an understanding of the issues they face, to demonstrate sensitivity, and to be aware of the most recent research on the topic. Research in the area of gender dysphoria continues to evolve, and even the terminology has changed dramatically over time. In the past this diagnosis was referred to as transsexualism and then, as recently as the last edition of this text, as gender identity disorder (GID). In the current version of DSM, the diagnosis has been renamed gender dysphoria. Because gender dysphoria is rare, there is a lack of the large-scale epidemiological studies, controlled treatment studies, and long-term follow-up studies that have been available for other DSM diagnoses, and readers should keep that fact in mind in reading this chapter.
The genetic sex of an individual is determined at conception, but development from that point on is influenced by many factors. For the first few weeks of gestation, the gonads are undifferentiated. If the Y chromosome is present in the embryo, the gonads will differentiate into testes. A substance referred to as the SRY antigen is responsible for this transformation. If the Y chromosome or SRY antigen is not present in the developing embryo, the gonads will develop into ovaries.
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Table 21-1. Definitions of core concepts |
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| Term | Definition |
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Disorder of sex development |
"Congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical" (Hughes et al. 2006, p. 149). These conditions have also collectively been called intersex, pseudohermaphroditism, and hermaphroditism. The terms variations of sex development and differences of sex development have also been suggested as alternatives to disorder (Diamond 2009). |
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Gender |
The socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women. These influence the ways that people act, interact, and feel about themselves. While aspects of biological sex are similar across different cultures, aspects of gender may differ (American Psychological Association 2012, p. 1). |
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Gender identity |
A person's internal sense of being male, female, or something else (American Psychological Association 2012, p. 1). |
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Gender expression |
The way in which a person acts to communicate gender within a given culture; for example, in terms of clothing, communication patterns, and interests. A person's gender expression may or may not be consistent with socially prescribed gender roles, and may or may not reflect his or her gender identity (American Psychological Association 2008, p. 28). |
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Sex |
A person's biological status, typically categorized as male, female, or intersex (i.e., atypical combinations of features that usually distinguish male from female). There are a number of indicators of biological sex, including sex chromosomes, gonads, internal reproductive organs, and external genitalia (American Psychological Association 2012, p. 1). |
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Sexual orientation |
An enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both sexes. Sexual orientation also refers to a person's sense of identity based on those attractions, related behaviors, and membership in a community of others who share those attractions. Research over several decades has demonstrated that sexual orientation ranges along a continuum, from exclusive attraction to the other sex to exclusive attraction to the same sex. However, sexual orientation is usually discussed in terms of three categories: heterosexual (having emotional, romantic, or sexual attractions to members of the other sex), gay/lesbian (having emotional, romantic, or sexual attractions to members of one's own sex), and bisexual (having emotional, romantic, or sexual attractions to both men and women). Sexual orientation is distinct from other components of sex and gender, including biological sex (the anatomical, physiological, and genetic characteristics associated with being male or female), gender identity (the psychological sense of being male or female), and social gender role (the cultural norms that define feminine and masculine behavior) (American Psychological Association 2008). |
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Transgender |
An umbrella term for persons whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth (American Psychological Association 2011). |
Like the gonads, the internal and external genital structures are initially undifferentiated in the fetus. If the gonads differentiate into testes, fetal androgen (i.e., testosterone) is secreted, and these structures develop into male genitalia (epididymis, vas deferens, ejaculatory ducts, penis, and scrotum). In the absence of fetal androgen, these structures develop into female genitalia (fallopian tubes, uterus, clitoris, and vagina). It is important to note that the development of genitalia in utero depends on the presence or absence of fetal androgen, from whatever source.
There can be a number of chromosomal differences that may or may not influence sexual differentiation and the expression of gender over the course of a lifetime. Individuals with these differences have in the past been called "inter-sex" as a group, and many individuals still identify using this moniker. However, recently the more common term in the literature is disorder of sex development (which has been added as a specifier in the new diagnostic criteria). Most of these sex chromosome and hormonal disorders can be quite rare (Blackless et al.